tbuckley/cabot-search huggingface dataset:
BI25 Immunotherapy-associated Sweet syndrome in a patient with metastatic melanoma
Authors: Rory Barry, Gregg Murray, Karen Eustace
Journal: British Journal of Dermatology (2023)

Abstract Ipilimumab, an anti-CTLA-4 monoclonal antibody, is used in the treatment of metastatic melanoma. As with other immune checkpoint inhibitors, it can cause a spectrum of immune-related adverse events (irAEs), including a cutaneous pathology, in 25% of patients. To date, there have been five case reports of Sweet syndrome solely due to ipilimumab therapy. We present a suspected further case in a patient with metastatic melanoma of unknown primary origin, who concurrently developed vitiligo. A 65-year-old man presented to the dermatology department with a 2-week history of a mildly tender, erythematous papulonodular rash localized to the right forearm. He had also developed extensive vitiligo on all limbs over a similar period of time. Histology from a skin punch biopsy demonstrated a predominantly neutrophilic dermal inflammatory infiltrate without features of vasculitis, confirming Sweet syndrome. There were no recent medication changes or disease recurrence on repeat imaging. Nine months prior, the patient had been diagnosed with cerebral and pulmonary metastatic melanoma of unknown primary origin (BRAF V600 mutation positive). He underwent an evacuation of a left temporal cortical mass and subsequent stereotactic radiosurgery. The oncology team then commenced ipilimumab (3 mg kg–1) and nivolumab (1 mg kg–1) every 21 days. Four cycles were completed until discontinuation after 3 months due to multiple severe irAEs, namely, panhypopituitarism and liver toxicity. He was commenced on 80 mg (1 mg kg–1) oral prednisolone, which was slowly reduced over subsequent months and completed a few weeks prior to the development of Sweet syndrome and vitiligo. We prescribed topical clobetasol propionate 0.05% once daily, with resolution of Sweet syndrome after 2 months. The oncology team elected to withhold further immunotherapy due to the multiple irAEs, instead monitoring for melanoma recurrence by serial radiological imaging. The five previously documented cases of ipilimumab-associated Sweet syndrome report an average time to clinical presentation of 8.9 weeks. Our case differs as the patient developed Sweet syndrome 5 months after the discontinuation of immunotherapy. However, the development of any cutaneous adverse effect may have been masked by high-dose steroids for the other systemic irAEs soon after the fourth cycle of treatment. Despite a lack of temporality between immunotherapy and Sweet syndrome in our case, the addition of vitiligo at the same presentation suggests an irAE. This case highlights the importance of monitoring patients on immunotherapy for dermatological side-effects and working closely with oncology colleagues to manage these complex cases.
CD06 Delving in to Disperse Orange 1
Authors: Sanaa Butt, Donna Thompson
Journal: British Journal of Dermatology (2023)

Abstract Disperse Orange 1, colour index 11080, is an azo dye. Collectively, azo dyes are a common cause of textile-related allergic contact dermatitis (ACD). A 2006 European Union (EU) directive restricts the sale of any articles or dyed items that have direct and prolonged contact with the skin or the oral cavity and contain more than 30-ppm azo dyes. These include a wide range of items such clothing, bedding, furniture, toys and yarn. Despite clear regulation set out by the directive, these dyes have been detected within garments produced and sold within the EU (https://echa.europa.eu/regulations/reach/legislation). In our cutaneous allergy clinic, we have patch tested a total of 547 patients to the clothing and dye series. Only seven (1.3%) have tested positive to Disperse Orange 1. We present a series of cases and highlight the suspected sources of exposure. We identified a total of seven patients, four of whom were male. Their ages ranged between 20 and 78 years. Aside from Disperse Orange 1, all patients developed positive patch test results to other disperse dyes. Three patients also reacted to paraphenylenediamine. Sites affected included the head and neck (n = 4), hands (n = 2), chest (n = 1) and leg (n = 1). Other series patients tested positive to included fragrances, metals, rubber, acrylates and local anaesthetics. Suspected sources of Disperse Orange 1 included hair dyes, clothing, wound dressings and a thyroid shield. Few cases of ACD have been published on Disperse Orange 1. One report noted a textile necklace as a source of a severe localized ACD (Nygaard U, Kralund HH, Sommerlund M. Allergic contact dermatitis induced by textile necklace. Case Rep Dermatol 2013; 5:336–9). We wish to raise awareness of the presence of problems with Disperse Orange 1, despite the EU directive. Members should consider a variety of sources, including traditional items such as clothing and hair dyes and also newer items such as dressings and thyroid shields, as suspected in our cases.
P81 Long-term efficacy of abrocitinib in adolescents and adults with moderate-to-severe atopic dermatitis: a post hoc analysis of JADE EXTEND
Authors: Amy S Paller, Michael J Cork, Carsten Flohr, Christine Bangert, Stephan Weidinger, John Nesnas, Saleem A Farooqui, Pinaki Biswas, Melissa Watkins, Herwig Koppensteiner
Journal: British Journal of Dermatology (2023)

Abstract Differences exist in the manifestation and disease course of atopic dermatitis (AD) between adult and adolescent patients. Long-term efficacy of abrocitinib (an oral, once-daily Janus kinase 1-selective inhibitor) was examined in the phase III extension study JADE EXTEND (NCT03422822). This interim post hoc analysis assessed abrocitinib treatment efficacy up to 96 weeks in adolescents and adults with moderate-to-severe AD who enrolled in JADE EXTEND. Eligible adolescents (aged 12 to &amp;lt; 18 years) and adults (≥ 18 years) from the phase III trials JADE MONO-1 (NCT03349060), MONO-2 (NCT03575871), COMPARE (NCT03720470), TEEN (NCT03796676) and DARE (NCT04345367) were enrolled in JADE EXTEND. Patients randomized to abrocitinib (200 mg or 100 mg) in the parent studies received blinded abrocitinib at the same dose in JADE EXTEND; those receiving placebo or dupilumab were randomized to either abrocitinib dose in JADE EXTEND. Patients from JADE DARE received abrocitinib 200 mg in JADE EXTEND. Analyses assessed the proportions of patients achieving an Investigator’s Global Assessment score of clear or almost clear (IGA 0/1); ≥ 75%, ≥ 90% and ≥ 100% improvement from baseline in Eczema Area and Severity Index (EASI-75, EASI-90 and EASI-100, respectively); ≥ 4-point improvement from baseline in Peak Pruritus Numerical Rating Scale score (PP-NRS4; used with permission from Regeneron Pharmaceuticals and Sanofi); PP-NRS score of no or very little itch (PP-NRS 0/1); and ≥ 4-point improvement from baseline in the Patient Oriented Eczema Measure (POEM ≥ 4). The JADE EXTEND data cutoff date was 25 September 2021. This analysis included 357 adolescents and 1309 adults (excluding patients previously randomized to dupilumab). Age at parent study screening visit determined age categorization. Baseline disease severity was higher in adolescents than adults [IGA 4 (severe); 42.3% vs. 36.7%]. At week 96, responder proportions were comparable for adolescents and adults for EASI-75 (abrocitinib 200 mg: 84.4% vs. 85.7%; abrocitinib 100 mg: 81.3% vs. 76.1%), PP-NRS4 (200 mg: 69.4% vs. 69.3%; 100 mg: 60.3% vs. 59.8%) and POEM ≥ 4 (200 mg: 84.4% vs. 88.6%; 100 mg: 79.2% vs. 80.8%), and largely comparable for the stringent endpoints of EASI-90 (200 mg: 62.3% vs. 61.1%; 100 mg: 50.7% vs. 48.1%), EASI-100 (200 mg: 32.5% vs. 21.8%; 100 mg: 18.7% vs. 18.7%), IGA 0/1 (200 mg: 53.2% vs. 55.9%; 100 mg: 49.3% vs. 45.1%) and PP-NRS 0/1 (200 mg: 42.9% vs. 39.5%; 100 mg: 33.3% vs. 32.3%). Long-term efficacy of abrocitinib treatment up to 96 weeks was comparable for adolescents and adults with moderate-to-severe AD, including substantial proportions achieving stringent endpoints of EASI-90, EASI-100, IGA 0/1 or PP-NRS 0/1. Funding sources: Pfizer Inc.
DS24 Prospective study comparing <i>ex vivo</i> confocal laser scanning microscopy and frozen section histopathology of 23 basal cell carcinomas treated with Mohs micrographic surgery
Authors: Sibel Demirel, Rachel Hill, Colin Fleming, Amina Khalid
Journal: British Journal of Dermatology (2023)

Abstract Ex vivo confocal laser scanning microscopy (CLSM) is an emerging technique that is used for the rapid analysis of freshly excised tissue during Mohs micrographic surgery (MMS). Previous studies on fluorescence CLSM have shown 88% and 99% sensitivity and specificity, respectively, of diagnosing basal cell carcinomas (BCCs) vs. conventional histology. The fourth-generation Vivascope 2500 allows fresh tissue to be scanned after minimal preparation with acetic acid and acridine orange, creating digitally coloured mosaic images, mimicking conventional histological haematoxylin and eosin slides. The scanning speed of &amp;lt; 3 min creates the potential to improve patient experiences, allowing multiple stages and repair in a single session, reducing overall operating times and improving efficiency. After a 2018 pilot study on a limited case series, we have begun the process of testing the real-world use of this technology. We present an initial prospective case series to assess BCC excision of stage 1 Mohs specimens using the Vivascope 2500 vs. conventional frozen section histology. Caldicot approval was sought. Over a 3-month period, 23 cases of stage 1 facial BCCs on one Mohs list were processed. Samples were obtained as standard bevelled Mohs excisions, and Mohs maps were created for all cases. There were three false-negative BCCs, of which two were infiltrative BCCs with small foci missed on the initial review on CLSM images and one superficial BCC not visible due to lack of epidermal capture. Of the four false-positive cases, the foci appearing to be BCC included inflammation in one, follicular structures in two and conjunctival glands misinterpreted as BCC in one eyelid case. Time taken to process specimens and read the digital images by CLSM was compared with the time taken to obtain and read frozen section slides. The shortest time recorded for CLSM and frozen sections was 6 min and 31 min, respectively. The longest time recorded for CLSM and frozen sections was 20 min and 57 min, respectively. In summary, CLSM shows promise in MMS for selected BCCs. Improved techniques to flatten the epidermis for better visualization and further experience with image reading and interpretation have the potential to minimize errors.
BT18 Evaluation of a teledermatology service for lesion monitoring
Authors: Radhika Bali, Jenny Chung, Chrystalla Macedo, Lucy Thomas, Louise Fearfield
Journal: British Journal of Dermatology (2023)

Abstract Teledermatology (TD) is an established diagnostic and triage tool for the initial assessment of skin lesions and is increasingly being used for monitoring. A previous study conducted at our trust found that 5% of our 2-week wait (2WW) referrals required follow-up for lesion monitoring. We therefore established a TD follow-up pathway to accommodate these patients and increase capacity for face-to-face (F2F) appointments. We retrospectively reviewed the outcomes of all TD follow-up patients seen from 1 April 2022 to 22 December 2022. The TD follow-up is usually requested 4 months after an initial assessment. We evaluated the proportion of benign lesions and those requiring further follow-up or surgery. In total, 3796 patients were assessed via TD, with 319 (8.4%) comprising TD follow-up. Altogether, 292 (91.5%) patients were initially reviewed via TD 2WW referral and 27 (8.5%) were referred from the clinic. Forty-eight (15.0%) did not attend (DNA) their follow-up and were discharged. Of the remaining 271 patients, seven (2.6%) who failed to attend their TD follow-up were rebooked, 179 (66%) were discharged after one TD follow-up assessment, 16 (5.9%) were booked for further TD follow-up, 19 (7.0%) were booked for routine F2F follow-up and five (1.8%) were booked for an urgent 2WW F2F appointment. Patients were also referred directly for excision, with 21 (7.7%) referred routinely and 24 (8.8%) referred urgently. From the 24 lesions excised urgently, five (21%) were dysplastic naevi, one (4%) was a moderately differentiated squamous cell carcinoma, 11 (46%) were benign (naevi, seborrhoeic keratoses or dermatofibroma) and for seven (29%), histology was unavailable (DNA appointment, sought private treatment or excision pending) at the time of data collection. No lesions were confirmed histologically as melanoma. Of the five dysplastic lesions, dermoscopic changes noted at follow-up included new atypical amorphous streaks, new and darker globules, loss of pigment and erythema. Our data suggest that TD for lesion monitoring may offer a suitable and time-efficient approach to follow-up, helping to alleviate pressure on services. Three to six months of follow-up has previously been considered an appropriate time period for short-term lesion monitoring; however, the optimal duration remains debatable. The low numbers of malignant lesions detected suggest an encouraging safety profile. However, with 66% of patients being discharged after TD follow-up, we plan to pilot a collaborative team approach to initial decision-making through mega processing clinics with the aim of improving specificity and ‘getting it right first time’ for patients. Longer-term data and cost-effectiveness analyses are required to further evaluate the sustained safety and efficacy of this service.
H05 Jean-Nicolas Marjolin (1780–1850): a name to remember
Authors: Kashini Andrew, Huda Al-Kutubi, Maryam Salimi, Pooja Patel, Stephen Orpin, Natalie King-Stokes
Journal: British Journal of Dermatology (2023)

Abstract Jean-Nicolas Marjolin was born in Ray-sur-Saone, in eastern France, in 1780. His education was sponsored by his mother as his father had died when he was 1 year old, leaving them impoverished. He studied Medicine at The Commercy Hospital, north-eastern France, before he left for Hôtel-Dieu hospital in Paris where he met Guillaume Dupuytren, who recruited him to the ‘Societe Anatomique’, a society created to promote the study of clinical anatomy. He became, successively, an assistant in anatomy (1805), a prosector (1806) and a doctor (MD) in 1808. He even established his own medical school in 1810. It was very popular as he admitted students from less privileged backgrounds to study medicine for free. His brilliant teaching style caused conflict with his ambitious mentor Dupuytren, who saw him as a threat after he was hired as Dupuytren’s assistant at Hôtel-Dieu. Marjolin was also a member of the Académie de Médecine, and surgeon to Louis-Philippe I, the French king at the time. His son René also became a surgeon and married Cornelia Scheffer, the daughter of the famous painter Ary Scheffer. In 1828, Marjolin described four types of ulcers that he named ‘ulcere verruqueux’ in Mimoires de l’Acadimie de Chirurgie, which was a manual of anatomy at that time. However, he did not specify whether the ulcers were malignant or associated with longstanding ulcers. In 1850, the year that Marjolin died, Robert Smith, Professor of Surgery at Trinity College, Dublin, described locally destructive ulcers that developed in scars following burns, floggings and lacerations as the ‘warty ulcers’ of Marjolin. After Smith’s death in 1873, Marjolin was again forgotten until 30 years later, when John Chalmers DaCosta, Professor of Surgery at Jefferson Medical College, Philadelphia, described two cases of carcinomatous change in chronic varicose leg ulcers as examples of Marjolin ulcers. John Fordyce, an American dermatologist, subsequently described a chronic ulcer undergoing malignant change as a Marjolin ulcer in 1907. These definitions of Marjolin ulcer by DaCosta and Fordyce included malignancy developing in sinuses, as well as malignancy in scars and persistent ulcers. These declarations defined the term ‘Marjolin ulcer’ in modern usage and preserved Marjolins’ name for future generations. Currently ‘Marjolin ulcer’ refers to a rare malignant transformation within chronic ulcers or scars with squamous cell carcinoma as the commonest subtype. Its exact cause remains unknown, despite being described by Jean-Nicolas Marjolin almost 200 years ago.
CD03 Contact sensitization to shellac: a possible marker of fragrance allergy
Authors: Sina Ghadiri, Pavan Sambi, Mark Wilkinson, Heather Whitehouse
Journal: British Journal of Dermatology (2023)

Abstract Shellac, the purified resin produced from the female lac bug (Kerria lacca), has its application within a wide range of industries, including healthcare, food, wood treatments and cosmetics. Shellac 20% alcohol is included in the British Society for Cutaneous Allergy/European Society of Contact Dermatitis extended facial series based on frequency of reactions exceeding the 0.3% threshold. However, the source of primary sensitization remains difficult to characterize through patch testing as relevance is not always clear and the test preparation has an irritant potential. We present a series of 28 patients from 2013 to 2022 with positive or irritant reactions to shellac, to elucidate its reaction pattern and relevance within our outpatient population. Cases with confirmed shellac positivity (‘+’ reactions and higher) or irritant reactions using a test preparation with alcohol 20% (Chemotechnique MB Diagnostics, Vellinge, Sweden) on days 2 and 4 of patch testing in a cosmetic series were retrieved between 2013 and 2022 from a total of 5458 people tested. Data collected from records included degree of positivity, irritancy, relevance, coexisting allergens, primary anatomical site and previous history of atopy. Data were processed using Microsoft Excel. We report 21 positive reactions, 14 (67%) of which were weak. Eleven (52%) positive reactions were deemed of current relevance, seven (33%) of doubtful relevance, one (5%) of past relevance and one (5%) a crossreaction to fragrance. Seven (25%) patients had documented irritant reaction to shellac. Nickel and colophony were the most common coexisting allergens in shellac-positive patients (positive in five and four cases, respectively). Nine (43%) cases with positive reaction had coexisting positivity of fragrance markers (which included one or more of geraniol, citral, Evernia furfuracea, turpentine, propolis, colophony, abitol, isoeugenol, cinnamyl alcohol, Jasminum officinale, jasmine absolute, majantole or benzaldehyde), indicating a higher prevalence than existing rates from studies in the general population. Fourteen (67%) positive cases documented the face as the primary site of disease, and 16 (76%) had a personal history of atopy. Our results indicate a significant association between shellac positivity and coexisting fragrance allergy, suggesting a role as a marker of fragrance allergy due to cross-reaction. When comparing irritant reactions to the proportion of positive reactions, this was higher than in previous US population-based reports (five irritant cases vs. 64 positive cases of a total cohort of 612 cases) but significantly lower than in a recent German population-based study (90 irritant cases vs. 76 positive cases of a total cohort of 2167), in all instances using the alcohol 20% preparation.
PA11 Congenital erosive and vesicular dermatosis healing with reticulated supple scarring and comedome-like lesions
Authors: Puo Nen Lim, Paula Beattie
Journal: British Journal of Dermatology (2023)

Abstract A 23 + 4-week gestational age female infant was born via spontaneous vaginal delivery following a premature spontaneous rupture of membranes (SROM). Pregnancy had been uneventful and antenatal scans were normal. After SROM, her mother was treated with intravenous antibiotics for septicaemia secondary to Escherichia coli infection. A vaginal swab 4 days prior to delivery grew group B streptococcus. The infant was subsequently prescribed benzylpenicillin and gentamicin for suspected chorioamnionitis. At 8 days old, she developed a vesicular eruption on her right shoulder, initially described as linear, which subsequently spread to affect both upper arms, back and buttocks. An older sibling was reported to have microcephaly and multiple developmental issues. Genetic testing for incontinentia pigmenti was negative, and the lesions subsequently evolved to form reticulate supple scarring-associated clusters of comedones. She was treated with adapalene 0.1% cream to aid remodelling of the epidermis. Congenital erosive and vesicular dermatitis (CEVD) is a rare disorder characterized by widespread superficial erosions and vesicles on the torso and limbs, with relative sparing of the face, palms and soles (Tlougan BE, Paller AS, Schaffer JV et al. Congenital erosive and vesicular dermatosis with reticulated supple scarring: unifying clinical features. J Am Acad Dermatol 2013; 69:909–15). The lesions typically heal within months to form supple dyspigmented scarring in a reticulate pattern. The CEVD can be associated with neurological abnormalities, ocular defects, hypoplastic or absent nails, cicatricial alopecia and hypohidrosis in areas of scarring with subsequent heat intolerance (Kong BY, Mancini AJ. Congenital erosive and vesicular dermatosis with reticulated supple scarring. Arch Dis Child Fetal Neonatal Ed 2018; 103:F78). The pathogenesis of CEVD is unclear, but proposed aetiologies include intrauterine infections, amniotic adhesions and birth trauma (Tlougan et al.). It is strongly associated with prematurity and being small for gestational age. This case is unique as the patient developed comedones, which has not been reported in other cases of CEVD. This adds to the wide clinical spectrum of CEVD. It is important for dermatologists to be aware of this condition as a differential diagnosis of vesicular eruption in neonates.